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Appendix UNAUTHORIZED DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)INCIDENT REPORT FORM REPORT TO BE COMPLETED BY PRIVACY AND SECURITY OFFICIAL. If there are supporting documents, attach them to
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The purpose of the report to be completed is to gather and organize relevant information for a specific purpose, such as decision-making or compliance.
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The specific information that must be reported on the report to be completed will vary depending on the requirements of the governing body or organization requesting the report.
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